UAB Office of Minority Affairs

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UAB Office of Minority Affairs

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Vendor Application

Vendor Search

Please complete this vendor application form and return to the address listed above.

Federal procurement regulations require that we update our vendor file. Therefore, it is essential that you respond to this request immediately.

Warning:
Failure to return this form will result in assumptions that may not accurately represent your company.

Vendor Name:

Order From Address:

City:

State:

Zip:

Phone:

Toll Free:

Fax:

Email Address:

Internet Address:

Customer Service Contact:

Sales Representative:
For Alabama

Phone:

Federal ID#:

Annual Sales Volume:

Year Company Established:

SS# if sole proprietorship:

Remit to name and address: ( if different form "order from" above )

	Vendor Name:
	Remit To Address:
	City:
	State:
	Zip:
	Accounts Receivable Contact Name:

Payment terms are "Net 30 Days" from date of invoice unless otherwise stated.

Terms:

Freight terms (check one only)

A - FOB Destination, freight prepaid
B - FOB Destination, freight prepaid and added to invoice
C - FOB Shipping Point, freight prepaid and added to invoice

List type of product/service(s) with the appropriate Standard Industrial Classification (SIC) for company:

The following information refers to company ownership. Contact your Regional or District U.S Small Business Administration Office if clarification is needed small or large business classification. (As defined by Code of Federal Regulation (CFR) 13 Part 121.)

Failure to return this form or failure to respond to this section will result in your company being classified as a large business concern.

PLEASE CHECK THE APPROPRIATE STATEMENTS:

This company is a:

F - Female-owned business
(Company must be 51% or more female-owed, controlled, and operated)
M - Male-owned business
SP - Sole Proprietorship (Must provide SS# if sole proprietorship)
NPR - Non-profit business
C - Corporation
P - Partnership

This company is a:

S - Small business L - Large business

This company is a:

Non-Disadvantaged
Disadvantaged: (To be considered disadvantaged, the company
      must be 51% or more owned, controlled, and operated by one or
      more of the following groups.)

1 - Black American 2 - Hispanic American

3 - American Indian 4 - Asian Pacific American

5 - Asian Indian American

6 - Other socially and economically disadvantaged group.
        Please specify:

7 - Disabled

This company is a:

CON - Contractor, specify type:
DIS - Distributor
MAN - Manufacturer
MAR - Manufacturer's Representative
RET - Retailer
SER - Service
WHO - Wholesaler
OTH - Other:

The undersigned certifies the information provided herein is correct to the best of his/her knowledge.

I Accept.

Name: Title:

Date: / /

Services Provided by UAB Office of Minority Affairs.